Specialized ESRD Nurse Practitioner

Duo Health•Jacksonville, FL

About The Position

Duo Health is a value-based care organization focused on improving outcomes for people living with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Its Health Mobilization™ platform connects multidisciplinary care teams with community nephrologists and other healthcare partners to provide comprehensive, high-touch care. Interprofessional teams include physician assistants, nurse practitioners, social workers, and care navigators, and use an intensive psychosocial model that includes assessment, medication management, social support, and behavioral health services. Duo Health is committed to building a workforce that reflects the diversity of the communities it serves. The Specialized ESRD Advanced Practice Provider delivers comprehensive care to patients with ESRD and late-stage CKD. The role manages a dedicated panel of approximately 100–125 patients, primarily through in-home visits and individualized clinical management. The APP collaborates with nephrologists, dialysis centers, and interdisciplinary care teams to improve outcomes, reduce avoidable hospitalizations, and coordinate care. The position primarily involves in-home patient visits across the assigned geographic market, with occasional travel for team meetings and training.

Requirements

Active, unrestricted Nurse Practitioner or Physician Assistant license in the state of practice.
Current national certification through an applicable certifying organization, such as ANCC, AANP, or NCCPA.
Experience managing complex chronic conditions in primary care, geriatrics, or a related clinical setting.
Strong clinical assessment, decision-making, and documentation skills.
Proficiency in electronic health records (EHR).
Strong communication and collaboration skills.
Valid driver's license and reliable transportation for in-home patient visits.
Commitment to patient-centered care and patient confidentiality.
Ability to travel between patient locations.

Nice To Haves

Experience in nephrology, dialysis, CKD, or ESRD management.
Experience in value-based care or Medicare Advantage.
Experience with quality improvement, risk adjustment, and utilization management.
CNN-NP (Certified Nephrology Nurse–Nurse Practitioner) certification or willingness to pursue nephrology-focused training.

Responsibilities

Manage a dedicated panel of 100–125 patients with ESRD and late-stage CKD (stages 4–5), primarily through in-home visits.
Assess and manage vascular access, anemia, fluid status, hypertension, and other ESRD-related conditions.
Coordinate with nephrologists and dialysis centers regarding treatment plans, dialysis adequacy, and patient needs.
Manage complex medication regimens, including renal dose adjustments and avoidance of nephrotoxic medications.
Identify transplant-eligible patients and initiate referrals as appropriate.
Complete post-hospitalization follow-ups and coordinate transitions of care.
Maintain accurate clinical documentation supporting HCC coding, risk adjustment, and quality measures.
Participate in team huddles, care coordination, clinical training, and continuous improvement initiatives.
Meet established goals related to quality, utilization, patient engagement, and clinical outcomes.
Adhere to company policies, HIPAA regulations, and applicable clinical and regulatory requirements.
Perform other duties as assigned by the supervisor.

Benefits

Competitive base compensation and performance-based bonus.
Medical, dental, and vision insurance.
Flexible Spending Account (FSA) and Health Savings Account (HSA) options.
Paid maternity, paternity, and parental leave.
Structured six-week onboarding and specialized ESRD clinical training.
Paid time off and company holidays.
401(k) with company match.
Malpractice coverage.
Annual continuing medical education (CME) opportunities.
Professional development opportunities, including support for nephrology-focused certification, in accordance with company policy.